The last thing that Mayra Ramirez remembers from the emergency room at Northwestern Memorial Hospital in Chicago is calling her family to say she had Covid, was about to be put on a ventilator and needed her mother to make medical decisions for her.
Ms. Ramirez, 28, did not wake up for more than six weeks. And then she learned that on June 5, she had become the first Covid patient in the United States to receive a double-lung transplant.
On Wednesday, she went home from the hospital.
Ms. Ramirez is one of a small but growing number of patients whose lungs have been destroyed by the coronavirus, and whose only hope of survival is a lung transplant.
“I’m pretty sure that if I had been at another center, they would have just ended care and let me die,” she said in an interview on Wednesday.
Her surgeon, Dr. Ankit Bharat, performed a similar operation on a second Covid patient, a 62-year-old man, on July 5.
The surgery is considered a desperate measure reserved for people with fatal, irreversible lung damage. Doctors do not want to remove a person’s lungs if there is any chance they will heal. Over all, only about 2,700 lung transplants were performed in the United States last year.
Patients must be sick enough to need a transplant, and yet also strong enough to survive the operation, recover and get back on their feet. With a new disease like Covid-19, doctors are still learning how to strike that balance.
“It’s such a paradigm change,” Dr. Bharat said. “Lung transplant has not been considered a treatment option for an infectious disease, so people need to get a little bit more of a comfort level with it.”
Two more patients at Northwestern are awaiting transplants, one from Chicago and one from Washington, D.C., said Dr. Bharat, who is the chief of thoracic surgery at Northwestern University Feinberg School of Medicine and surgical director of the lung transplant program at Northwestern Medicine, which includes Northwestern Memorial Hospital.
A patient is to be flown in from Seattle next week, and the Northwestern team is consulting on still another case with a medical group in Washington, D.C. Other transplant centers are considering similar surgeries, Dr. Bharat said.
Last Friday, a Covid-19 patient underwent a double lung transplant at the University of Florida Health Shands Hospital in Gainesville, Dr. Tiago Machuca said.
While other centers have sought to refer cases, most of the patients had other serious medical problems that ruled them out, he said.
In some cases, Dr. Bharat said, hospitals appeared to have waited too long to recommend a transplant. One patient being referred to his center seemed like a good candidate but then had major bleeding into the lungs as well as kidney failure, and the surgery was no longer feasible.
“I think people need to recognize this option earlier and just start at least talking about it before it gets to that point,” Dr. Bharat said.
In some cases, he said, insurers’ reluctance to cover the surgery or to pay for travel to transfer patients has led to delays.
“This is so new to our field,” Dr. Machuca said. “It will be a challenge for physicians to determine which patients truly are candidates and what’s the timing. We don’t want to do it too early when the patient still can recover from Covid lung disease and resume with good quality of life, but also you don’t want to miss the boat and have a patient where it’s futile, the patient is too sick.”
He said that, in some cases, extensive rehabilitation has brought about recovery in Covid patients who were being considered as possible transplant candidates.
Because the extensive lung damage in Covid patients makes transplant surgery especially difficult, most patients would be referred to major transplant centers that are best equipped to perform the risky operations and provide the intensive aftercare that patients need, the surgeons said.
Before she became ill, Ms. Ramirez, a paralegal for a law firm specializing in immigration, was working from home and having her groceries delivered. She was in good health, but had an autoimmune condition, neuromyelitis optica, and took medication that suppressed her immune system and might have made her more vulnerable to the coronavirus infection.
She was ill for about two weeks, and consulted with a Covid hotline about her symptoms. At one point, she headed to the hospital but then turned back without going in. She dreaded the idea of being admitted, and told herself she would recover.
But on April 26, her temperature reached 105 degrees Fahrenheit, and she was so weak that she fell when she tried to walk. A friend drove her to the hospital. When doctors told her that she needed a ventilator, she had no idea what they meant. She thought it meant some kind of fan, like the word in Spanish.
“I thought I’d just be there for a couple of days, max, and get back to my normal life,” she said.
But she spent six weeks on the ventilator, and also needed a machine to provide oxygen directly into her bloodstream.
“The entire time, I had nightmares,” she said.
Many of the nightmares involved drowning, her family saying goodbye, the doctors telling her she was going to die.
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Frequently Asked Questions
Updated July 27, 2020
Should I refinance my mortgage?
- It could be a good idea, because mortgage rates have never been lower. Refinancing requests have pushed mortgage applications to some of the highest levels since 2008, so be prepared to get in line. But defaults are also up, so if you’re thinking about buying a home, be aware that some lenders have tightened their standards.
What is school going to look like in September?
- It is unlikely that many schools will return to a normal schedule this fall, requiring the grind of online learning, makeshift child care and stunted workdays to continue. California’s two largest public school districts — Los Angeles and San Diego — said on July 13, that instruction will be remote-only in the fall, citing concerns that surging coronavirus infections in their areas pose too dire a risk for students and teachers. Together, the two districts enroll some 825,000 students. They are the largest in the country so far to abandon plans for even a partial physical return to classrooms when they reopen in August. For other districts, the solution won’t be an all-or-nothing approach. Many systems, including the nation’s largest, New York City, are devising hybrid plans that involve spending some days in classrooms and other days online. There’s no national policy on this yet, so check with your municipal school system regularly to see what is happening in your community.
Is the coronavirus airborne?
- The coronavirus can stay aloft for hours in tiny droplets in stagnant air, infecting people as they inhale, mounting scientific evidence suggests. This risk is highest in crowded indoor spaces with poor ventilation, and may help explain super-spreading events reported in meatpacking plants, churches and restaurants. It’s unclear how often the virus is spread via these tiny droplets, or aerosols, compared with larger droplets that are expelled when a sick person coughs or sneezes, or transmitted through contact with contaminated surfaces, said Linsey Marr, an aerosol expert at Virginia Tech. Aerosols are released even when a person without symptoms exhales, talks or sings, according to Dr. Marr and more than 200 other experts, who have outlined the evidence in an open letter to the World Health Organization.
What are the symptoms of coronavirus?
- Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
Does asymptomatic transmission of Covid-19 happen?
- So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
The disease was relentless. Bacterial infections set in, scarring her lungs and eating holes in them. The lung damage caused circulatory problems that began to take a toll on her liver and heart.
The doctors told her family in North Carolina that it might be time to come to Chicago to say goodbye, and her mother and two sisters made the trip.
But Ms. Ramirez held on, cleared the coronavirus from her body and was placed on the transplant list. Two days later, on June 5, she underwent a grueling, 10-hour operation.
She woke scarred, bruised, desperately thirsty and unable to speak, “with all these tubes coming out of me, and I just couldn’t recognize my own body.”
The nurses asked if she knew the date. She guessed early May. It was the middle of June.
She was not told she’d had a lung transplant until several days after she woke up.
“I couldn’t process it,” she said. “I was just struggling to breathe and I was thirsty. It wasn’t until weeks later that I could be grateful, and think there was a family out there who had lost someone.”
Before her illness, she worked full-time and enjoyed running and playing with her two small, scrappy dogs. Now, she still feels short of breath, can walk only a short distance and needs help to shower and stand up from a chair. The dogs were overjoyed at her homecoming, but their energy was a bit much. Her mother, who lives in North Carolina, took time away from her job at a meatpacking plant and traveled to Chicago to help her recover.
Ms. Ramirez said she was learning to use her new lungs and getting stronger every day.
She is looking forward to getting back to work, but she still has a way to go. Her family is assisting her, and a friend started a GoFundMe page to help pay the bills.
“I definitely feel like I have a purpose,” Ms. Ramirez said. “It may be to help other people going through the same situation that I am, maybe even just sharing my story and helping young people realize that if this happened to me it could happen to them, and to protect themselves and protect others around them who are more vulnerable. And to motivate and help other centers around the world to realize that lung transplantation is an option for terminally ill Covid patients.”
The outlook for Ms. Ramirez is good, Dr. Bharat said, because she is young and healthy. She will be on anti-rejection medicines for the rest of her life. Transplanted lungs can still be rejected, he said, but he has seen some last 20 years. And patients may be able to receive a second transplant.
“I think from now on she’ll continue to get stronger and stronger,” he said. “She asked if she could go skydiving. We’ll probably get her there in a few months.”